Managing Urothelial Recurrences after Chemoradiation Therapy

The management of urothelial recurrences following trimodal therapy (TMT) for bladder cancer is dependent on the nature and location of the recurrence – non-muscle-invasive or muscle-invasive, versus upper tract or urethral. Non-muscle-invasive recurrences can be managed similarly to how any recurrent non-muscle-invasive urothelial carcinoma is managed. It requires transurethral resection of the bladder tumor to provide accurate staging and completely resect the recurrence. Intravesical therapy has been described in these patients following TMT. In available studies, almost 20% of patients progressed to muscle-invasive disease. Muscle-invasive recurrences should be managed with radical cystectomy if patient desires a curative management plan. Despite historic concerns regarding operating in an irradiated pelvis, salvage radical cystectomy can safely be performed in post-TMT patients and survival outcomes appear similar to those for radical cystectomy as primary management of muscle-invasive urothelial carcinoma. There are limited data regarding upper tract recurrences following TMT, but they can generally be managed similarly to those occurring in non-irradiated bladder. Similarly, data on urethral recurrence following TMT are sparse and clinicians can follow current guidelines for its management. The only role for additional radiation in the post-TMT patient is a palliative one, for intractable hematuria or pelvic pain.